Effectiveness of Smartphone-Based Lifestyle Interventions on Women with Gestational Diabetes: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Figures & data

Figure 1 PRISMA flow diagram.

Notes: PRISMA figure adapted from Liberati A, Altman D, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. Journal of clinical epidemiology. 2009;62(10). Creative Commons.³⁴

Table 1 Characteristics of Included Studies

Study, Year (Reference); Location, Design	Sample Characteristic (P)								Intervention Characteristic (I)						Framework	Drop Out (%)
	Group	N	Age (Years) Mean ±SD	Mean BMI (kg/m ^2) Mean ±SD	HbA1c at Diagnosis (%) Mean ±SD	Gestation at Recruitment (Weeks) Mean ±SD	Plasma Glucose on OGTT (mmol/L) 2h	History of Previous GDM n (%)	Content	Intervention Period	Technical Support	Frequency	Venue	Interventionist
Sophie E. Poulter,2022,^Citation43 Australia. A single-center, two-arm pilot RCT.	I	98	31.9 ±5.4	NR	NR	28.2 ±2.1	NR	15 (15)	NET-Health smartphone application intervention and routine care. NET-Health allowed automatic upload of BGL values and generate alert if it was not an eligible target.	24–30 weeks of gestation to delivery	NET-Health App	Everyday	Home	A dietitian or a licensed diabetes educator	NR	0
	C	94	32.4 ±5.7	NR	NR	28.6 ±1.7	NR	11 (12)	Routine care, including dietary and lifestyle modifications, self-blood glucose monitoring, and record blood glucose level in a paper diary		Paper diary	Reviewed every 2–4 weeks	Hospital	By phone, email, or clinic review	NR	0
Tong Wei Yew, 2021,^Citation41 Singapore, A single-center, two-arm RCT	I	170	31.7 ±4.0	25.5 ±5.5	5.3 ±0.4	27.0 ±3.2	8.6 ±1.4	19 (11.3)	12 interactive lessons including diet, SMBG, physical activity, and weight tracking tools; and a messaging platform with health care professionals.	12–30 weeks of gestation to delivery	Habits-GDM App	12 interactive lessons feedback every day.	Home	Health care teams	Health Belief Model	1.76%
	C	170	32.2± 4.4	25.6 ±5.7	5.3 ±0.4	26.7 ±3.7	8.6 ±1.3	21 (12.7)	Education session: the sessions covered pathophysiology and complications of GDM, healthy eating, carbohydrate exchange, SMBG, and future risk of diabetes. Advice on diet and lifestyle modification and initiation of insulin and/or metformin was individualized on the basis of SMBG results.		NR	2–3 days a week	Hospital	A diabetes nurse educator and dietitian	NR	3.5%
Karen Lim, 2021,^Citation42 Singapore. A single-center, two-arm RCT	I	96	32.6± 4.5	X	5.4±0.3	27.1 ±2.0	8.4 ±1.4	13 (13.5)	Interactive Smartphone App: Goal Setting, Food choices and recommendations. Activity and steps tracker, Interactive video lessons, Healthcare Professionals Support	Between six weeks and four months after postpartum	Nutritionist Buddy (nBuddy)	A total of 16 video clips (3 minutes per video). Feedback every day.	Home	Dieticians, a physiotherapist, and an occupational therapist.	Obesity-Related Behavioral Intervention Trials model	5.9%
	C	93	32.4± 4.2	X	5.2±0.4	27.0 ±1.7	8.7 ±1.2	13 (14.0)	A follow-up appointment at 6 weeks postpartum include providing dietary advice and performing an OGTT.		NR	NR	Hospital	Clinician		12.1%
Iren Borgen, 2019,^Citation40 Norway A multi-center, two-arm RCT	I	112	NR	NR	NR	NR	NR	23 (33.8)	Pregnant+ app and usual care: diet, being physically active, management of GDM and receiving feedback on their blood glucose levels. It contains four main icons: “Blood glucose”, “Physical activity”, “Food and beverages”, and “Diabetes information”.	≤33 weeks of gestation to delivery	Pregnant+ app	Every day	Home	NR	NR	2.6%
	C	121	NR	NR	NR	NR	NR	19 (31.7)	Usual care consists of information about a healthy diet, regular physical activity, measure / record blood glucose levels.		Paper diary	Every second week	Hospital	Midwives and/or diabetes nurses	NR	1.6%
H. Guo, 2019^Citation48 China. A single-center, two-arm RCT	I	64	31.2± 4.1	25.7± 3.3	6.0± 0.4	24.7± 5.1	9.7±1.3	10 (15.6)	Standard care and mobile health. Additional mobile medical management refers to nurse providing personalized online instruction which include diet, exercise, blood glucose monitoring, insulin injection.	24–28 weeks of gestation to delivery	Dnurse App	Every day	Home	Outpatient service doctor and education nurse.	NR	0
	C	60	30.6± 3.1	25.6± 2.9	5.9± 0.3	25.1± 3.5	9.9± 1.5	9 (15.0)	Standard care: diet, exercise, monitoring blood glucose and performing OGTT after delivery 3 months.		Paper diary	One visit a week for 3 consecutive weeks. at least 3 days per week until delivery.	Hospital	Educational nurse	NR	0
Ji-Hee Sung,2019.^Citation45 Korea, A single-center, two-arm pilot RCT	I	11	35.0± 2.76	24.69± 4.45	NR	27.29±1.92	NR	NR	Standard antenatal care and tailored mobile health care services. The application comprised 4 sections: clinical data, nutrition and diet, medication, and messaging system and information.	24–28 weeks of gestation to delivery	Mobile phone application	Twice a week	Home	Health care providers	NR	0
	C	10	31.7± 4.92	26.28±3.51	NR	27.39± 1.61	NR	NR	Standard antenatal care including record their blood glucose, blood pressure, and intake meal.		NR	Biweekly visits up to 36 weeks of gestation, followed by weekly visits until delivery	Hospital	Obstetricians and endocrinologists	NR	0
Hadas Miremberg, 2018,^Citation47 Israel A single-center, two-arm RCT	I	60	31.7± 4.2	27.1± 5.1	5.2± 0.33	NR	NR	12 (20)	Stand care and smartphone-based intervention. Patients received individualized feedback from clinic team regarding her daily glycemic control, eg, dietary tips, insulin treatment.	< 34 weeks of gestation to delivery	Mobile application	Every day (including weekends)	Home	Maternal-fetal medicine specialist and endocrinologist)	NR	7.7%
	C	60	32± 6.3	27.1± 5.2	5.2± 0.4	NR	NR	18 (30)	Standard care: routine prenatal care, physical activity, blood pressure monitoring, urine dipstick for proteinuria, and blood glucose measurements.		Paper diary	Bi-weekly visits up to visits from 35 weeks of gestation, weekly visits from 35 weeks of gestation until delivery	Hospital	Medicine specialist, nurse, dietician	NR	1.6%
Lucy Mackillop, 2018,^Citation44 UK, A single-center, two-arm RCT	I	101	33.9±5.5	31.1± 6.7	5.42± 0.34	30.9±3.6	7.4± 2.2	10 (13.8)	Additional daily detailed feedback from the clinic team via mobile app containing advice about diet, dose adjustments of hypoglycemic medications, and messages of encouragement.	< 34 weeks of gestation to delivery	GDm-health app	Once a week	Home	Diabetes midwife	NR	1.9%
	C	102	33± 5.6	31.6± 7.3	5.39±0.35	31± 3.4	7.0± 1.9	7 (11.7)	Standard Care: routine biweekly prenatal clinic care		Paper diary	Every 2 to 4 weeks, until delivery.	Hospital	Diabetes midwife	NR	1%
Ping Yang, 2018,^Citation49 China, A single-center, three-arm RCT	I	57	31.61±4.16	NR	NR	NR	8.90± 1.82	NR	Individualized dietary advice, self-monitor glucose levels	24–28 weeks of gestation to delivery	WeChat platform system	Every day.	Home	Obstetrician and qualified dietitian	NR	0
	C	50	32.22±4.69	NR	NR	NR	9.84± 1.77	NR	Usual care: routine outpatient clinic treatment and health education guidance.		NR	NR	Hospital	NR	NR	0
NataliaPérez-Ferre, 2010,^Citation46 Spain, A single-center, two-arm RCT	I	49	33.33 ± 5.58	NR	5.03 ± 0.38	NR	NR	4 (8.2)	Short messaging Service (SMS): patients send their blood glucose values via SMS and the professional makes recommendations.	24–28 weeks of gestation to delivery	Short messaging Service	Every day	Home	An endocrinologist and a diabetes nurse educator	NR	2%
	C	48	34.19 ± 5.18	NR	5.10 ± 0.41	NR	NR	9 (18.8)	Usual care: face-to-face outpatient clinic visits		Paper diary	Any time	Hospital	NR	NR	4%

Note: X refers to data not available.

Abbreviations: RCT, Randomized Controlled Trials; NR, Not Report; I, Intervention; C, Control; OGTT, Oral Glucose Tolerance Test; SMBG, Self-Monitoring of Blood Glucose; HbA1c, Hemoglobin A1c.

Table 2 Content of Lifestyle Interventions of Included Studies

Study, Year, (Reference);	Lifestyle Interventions
	Diet	Physical Activity	SMBG	Weight Tracking	A Messaging Feedback/Interaction	Health Education	Blood Glucose	Insulin Treatment
Sophie E. Poulter, 2022^Citation43	X	X			X		X
Tong Wei Yew, 2021^Citation41	X	X	X	X	X
Karen Lim, 2021^Citation42	X	X			X	X
Iren Borgen, 2019^Citation40	X	X			X	X	X
H. Guo, 2019^Citation48	X	X	X		X	X	X	X
Ji-Hee Sung, 2019^Citation45	X	X			X	X	X
Hadas Miremberg, 2018^Citation47	X				X	X	X	X
Lucy Mackillop, 2018^Citation44	X				X	X	X
Ping Yang, 2018^Citation49	X			X	X	X	X
NataliaPérez-Ferre, 2010^Citation46	X				X		X	X

Note: X refers to the content of lifestyle interventions available.

Abbreviation: SMBG, Self-Monitoring of Blood Glucose.

Table 3 Outcome Measures Available for Meta-Analysis

Glycemic Control Outcomes			Maternal and Neonatal Outcomes							Psychology Outcomes
Study, Year, (Reference);	Compliance	HbA1C (%)	Infant Birth Weight (Grams)	Gestational Age at Delivery (Week)	Neonatal Hypoglycemia, n (%)	NICU Admission, n (%)	Gestational Weight Gain (Kg)	Normal Vaginal Delivery, n (%)	Cesarean Delivery, n (%)	Depression	Anxiety
Sophie E. Poulter, 2022^Citation43			I:3362 ±445; C:3310± 456	I:38.9 ±1.3; C:38.4 ±1.1	I:19 (19); C:24 (25)	I:22 (22); C:31 (33)		I:11 (11); C:10 (11)	I:37 (37); C:59 (35.8)
Tong Wei Yew, 2021^Citation41	I:12 ±5; C:12 ±6		I:3055.5± 414.9; C: 3064.8± 489.0	I:38.5 ±1.9; C:38.7 ±1.1	I:24 (14.3); C:37 (22.4)	I:12 (7.1); C:21 (12.7)	I:9.03 ±4.99; C:8.44 ±3.88	I:104 (61.9); C:97 (58.8)	I:57 (33.9); C:37 (39)	I:5.1 ±4.1; C:5.3 ±4.3	X
Karen Lim, 2021^Citation46							I:8.84 ±4.2; C:9.19 ±4.7
Iren Borgen, 2019^Citation40			X			I:14 (12.5); C:20 (16.5)		I:90 (80); C:86 (71)	I:22 (112); C:35 (121)
H. Guo, 2019^Citation48	I:83.3±12.5; C:70.4 ±10.1	I:4.7 ±0.2; C:5.3 ±0.3		I:38.1±1.6; C:37.8 ±2.5	I:1 (1.6); C:2 (3.3)		I:3.2 ±0.8; C:4.8 ±0.7	I:48 (75); C:40 (66.7)	I:16 (25.0); C:20 (33.3)
Ji-Hee Sung,2019^Citation45			I:3280± 530; C: 3210± 370	I:38.74±1.03; C:39.44±0.70			I:1.98 ±2.05; C:3.658 ±1.71
Hadas Miremberg, 2018^Citation47	I:84±0.16; C:66 ±0.28		I:3097.8± 548.2; C: 3203.3± 414.6	I:38.2±1.7; C:38.5±1.4	I:2 (3.3); C:1 (1.7)	I:6 (10); C:7 (11.6)		I:48 (80); C:40 (67.7)	I:12 (20); C:20 (33.3)
Lucy Mackillop, 2018^Citation44		X	I:3440± 516 C: 3338±559		I:31 (32.3); C:25 (26.9)	I:5 (5.0); C:12 (12.1)	I:1.23 ±0.96; C:1.19 ±1.20	I:52 (51.4); C:42 (41.2)	I:49(48.5); C:60 (58.8)
Ping Yang, 2018^Citation49			I:3199.47±389.53; C: 3169.60± 524.03		I:0 (0%); C: 2 (4%)	I: 2 (57); C: 4 (50)		I: 37(57); C:40(50)	I: 18(57); C: 7(50)
NataliaPérez-Ferre, 2010^Citation46		I:5.3 ±0.4; C:5.4 ±0.4	I:3308.2± 488.8; C: 3370.6± 479.1	I:39.12±1.66; C:39.42±1.42	I: 1 (2%); C: 0 (0%)		I:5.82 ±3.95; C:6.45 ±4.99	I: 20 (40.8); C: 26 (54.2)	I: 17 (34.7); C: 12 (25)

Note: X refers to data not available.

Abbreviations: I, Intervention; C, Control; HbA1c, Hemoglobin A1c; NICU, Neonatal Intensive Care Unit.

Table 4 Summary of Quality Assessment of Studies by the Cochrane Risk-of-Bias Tool (RoB 2)

Studies	Randomization Process	Deviations from Intended Interventions	Missing Outcome Data	Measurement of the Outcome	Selection of the Reported Result	Overall Bias
Sophie E. Poulter, 2022^Citation43	Some concerns	Some concerns	Low	High	Some concerns	High
Tong Wei Yew, 2021^Citation41	Low	Some concerns	Low	Low	Low	Some concerns
Karen Lim, 2021^Citation46	Low	Some concerns	Low	Low	Some concerns	Some concerns
Iren Borgen, 2019^Citation40	Low	Some concerns	Low	Low	Some concerns	Some concerns
H. Guo, 2019^Citation48	Some concerns	Some concerns	Low	High	Some concerns	High
Ji-Hee Sung,2019^Citation45	Some concerns	Some concerns	Low	High	Some concerns	High
Hadas Miremberg, 2018^Citation47	Low	High	Low	Low	Low	High
Lucy Mackillop, 2018^Citation44	High	High	Low	Low	High	High
Ping Yang, 2018^Citation49	High	Some concerns	Low	Low	Low	High
NataliaPérez-Ferre, 2010^Citation46	Some concerns	Some concerns	Low	Low	Low	Some concerns

Figure 2 Forest plot of compliance.

Figure 3 Forest plot of HbA1C.

Figure 4 Forest plot of gestational weight gain.

Figure 5 Forest plot of gestational age at delivery.

Figure 6 Forest plot of normal vaginal delivery.

Figure 7 Forest plot of cesarean delivery.

Figure 8 Forest plot of Infant birth weight.

Figure 9 Forest plot of neonatal hypoglycemia.

Table 5 Effect Sizes for Primary and Secondary Outcomes from RCTs

Outcome	Studies	Participants	Statistical Method	Effect Estimate	I^2	Z	P
1. Compliance	3	584	Std. Mean Difference (IV, Random, 95% CI)	7.36 [4.05, 10.68]	99	4.35	< 0.0001**
2. HbA1C	2	221	Std. Mean Difference (IV, Random, 95% CI)	−1.30 [−3.36, 0.77]	98	1.23	0.22
3. Gestational weight gain	6	905	Std. Mean Difference (IV, Random, 95% CI)	−0.47 [−1.05, 0.11]	94	1.59	0.11
4. Gestational age at delivery	7	1001	Std. Mean Difference (IV, Random, 95% CI)	0.02 [−0.21, 0.24]	65	0.15	0.88
5. Normal vaginal delivery	8	1409	Risk Ratio (M-H, Fixed, 95% CI)	1.07 [0.98, 1.16]	35	1.51	0.13
6. Cesarean delivery	8	1409	Risk Ratio (M-H, Fixed, 95% CI)	0.89 [0.77, 1.03]	43	1.58	0.11
7. Infant birth weight	7	1072	Mean Difference (IV, Fixed, 95% CI)	9.98 [−46.75, 66.71]	0	0.34	0.73
8. Neonatal hypoglycemia	7	1162	Risk Ratio (M-H, Fixed, 95% CI)	0.83 [0.64, 1.09]	6	1.35	0.18
9. NICU admission	6	1185	Risk Ratio (M-H, Fixed, 95% CI)	0.64 [0.47, 0.86]	0	3.00	0.003*

Notes: *Statistically significant at P < 0.05 level; **Statistically significant at P < 0.0001 level.

Abbreviations: HbA1c, Hemoglobin A1c; NICU, Neonatal Intensive Care Unit.

Figure 10 Forest plot of NICU admission.

Figure 11 Funnel plot.

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